Editor’s note: The following letter is in response to the article titled, “Applying the Four Basic Principles of Medical Ethics to Artificial Intelligence,” which was published in the July issue of AAOS Now.
Some opine that the evidence that patient-reported outcome measures are influenced by mental and social health might lead to increased health disparities. In my opinion, the increasing evidence in this area prompts us to rethink what constitutes health in a way that is likely to decrease bias, unwarranted variation, and disparities. As analyses of increasing amounts of improved quality data clarify the relationship among pathophysiology, mindset, and circumstances, I envision an evolution toward more balance in the attention and resources devoted to mindset and circumstances, along with attention and resources invested in pathophysiology.
I anticipate that computer models approximating human intelligence (and therefore too complex for us to easily understand compared to standard regression models) might make it more intuitive and automatic that illness (the experience of being unwell) does not correspond precisely with disease (objective pathophysiology). Data and data analyses are tools, just as our training, wisdom, and intuition are tools. With good enough data, the probabilities generated by computer programs may be more accurate and reliable (less biased or prone to error) than those generated by human intelligence. If this becomes the norm, the role of the clinician will change from probability calculator to compassionate guider—a guider toward an awareness of one’s values; a guider regarding the cognitive and emotional aspects of living with pathophysiology; a guider through the unexpected and counterintuitive situations in health; a guider from false hope and wishful thinking toward efforts that are known to improve health. Given the evidence that such guidance is improved by effective relationships based in trust and compassion, many of us think computers will find it difficult to replace these aspects of doctoring.
I’m optimistic that analysis of data will make humans increasingly comfortable with uncertainty and willing to reorient their thoughts. These tactics are both effective cognitive coping strategies associated with fewer symptoms and limitations. I’m also optimistic that these tools can reduce clinician-to-clinician variations and help ensure that any variations are based on what matters most to patients—their values.
When people understand that surgery is one element—in most cases discretionary—of optimal musculoskeletal health and understand that the benefits of surgery may be increased relative to the potential harms by attending to healthy intake, activity, mindset, and circumstances, they are likely to become more patient and resolved to place hope in interventions other than those that address pathophysiology and may create the false hope of a “quick fix.” Improved data and analytics, along with increasing application of implementation science (strategies based on the science of choice, bias, communication, relationships, etc.), can help support these improvements in whole-person, comprehensive care. Using data to optimize the physical, mental, and social health of a person considering discretionary surgery can both improve the risk/benefit ratio of the surgery and, in some cases, give a person a firm health foundation that might allow him or her to avoid surgery altogether.
I’m optimistic that with more data, we can conduct more sophisticated analyses. As an example of what this might add, such analyses might establish that social constructs (concepts that exist because members of a society agree to behave as if they exist) such as race and ethnicity have less influence than objective factors such as specific genes, socioeconomic status, and lived experience (e.g., structural racism and sources of stress). These endeavors might even result in universal agreement that it is unethical and immoral to ignore or deprioritize health disparities.
David C. Ring, MD, PhD, is chair of the AAOS Patient Safety Committee, as well as the associate dean for comprehensive care and professor of surgery and psychiatry at Dell Medical School at the University of Texas at Austin.